Asylum seekers: Forensic remarks regarding 185 cases

Abstract

The medical examination of asylum seekers plays a significant role in helping them to obtain any form of international protection (refugee status or subsidiary or humanitarian protection). The Brescia Institute of Forensic Medicine has been increasingly involved in the medical examination of alleged victims of torture. Based on the Istanbul Protocol, the purpose of this study was to correlate the degree of consistency between the information provided by asylum seekers and the results of clinical examinations. A total of 185 asylum seekers were examined between September 2008 and September 2017. Almost all of the victims were male (94.0%) and aged between 11 and 30 years old (89.2%). Most victims were from Nigeria (23.2%), Gambia (16.2%) and Mali (10.8%), and the majority of the aggressions happened in Nigeria (18.9%), Gambia (14.5%) and Libya (12.9%). More than half of the instances of torture were related to political motives (57.3%); in 22% of cases, the victims referred to more than one act of aggression at different times. Blunt instruments were the most frequent means of injury (33.8%), followed by sharp instruments (23.3%). The most commonly involved anatomical regions were the lower and the upper limbs (23.6% and 20.5%, respectively). In terms of the degree of consistency between the lesion and the alleged torture, 50.4% of lesions were consistent with the information provided by the asylum seekers.

Keywords

Asylum seekers refugee torture

Introduction

The migratory flow to Europe has been continuously increasing, with 147,370 political refugees and 123,600 asylum seekers being registered in Italy in 2016.¹ The right of people to seek asylum from persecution in other countries was recognised in 1948 by the Universal Declaration of Human Rights. Referring to the 1951 United Nations Convention and Protocol Relating to the Status of Refugees,² a refugee is someone who is unable or unwilling to return to his/her country of origin due to fear of being persecuted because of race, religion or nationality or being part of a particular social group or political opinion. Until the point where the court assigns the status of ‘refugee’, the person is considered an asylum seeker who has the right to stay in other countries. In 2004, the Council of the European Union declared that people who are not recognised as refugees but have a risk of serious harm if they return to their country should be granted subsidiary protection. People living in specific social contexts can ask for humanitarian protection in order to prevent risks and consequences of violence and abuse.³ Many asylum seekers have suffered different forms of persecution, including torture. The definition of torture given by the 1948 Universal Declaration of Human Rights is ‘any act by which severe pain or suffering whether physical or mental is intentionally inflicted on a person’.⁴ Identifying signs of torture is not easy, and in almost every case, victims undergo a medical examination a long time after the event. The Istanbul Protocol Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment provides reliable guidelines on performing a forensic evaluation of asylum seekers.⁵ In Italy, Legislative Decree no. 25 of 2008 sets out the rules for the recognition of International Protection, identifying 20 Territorial Commissions. One of these is located in Brescia, which is one of the Italian northern counties with the highest number of asylum seeker. From 2008, the Brescia Institute of Forensic Medicine has been increasingly involved in the medical examination of alleged victims of torture. The medical examination of asylum seekers plays a significant role in protecting them in order to help them to obtain any form of international protection (refugee status or subsidiary or humanitarian protection). The purpose of this study was to assess the degree of consistency between the information given by asylum seekers and the results of medical examinations, according to the Istanbul Protocol.

Method

The municipality of Brescia cooperates with humanitarian non-profit associations and gives asylum seekers who are willing the opportunity to undergo a medical examination and forensic evaluation. An interpreter is always available. A total of 185 asylum seekers were examined at the Brescia Institute of Forensic Medicine between September 2008 and September 2017. The following data were analysed for every case: alleged victims’ characteristics (sex, age and nationality), information about the supposed torturing event (date, time, place, motive, method and mean(s)) and the features of the injuries (photos were always taken). Any kind of imaging evaluation (radiography, computed tomography (CT)/magnetic resonance imaging scans or ultrasound scan) or specialist examination previously performed was acquired.

Results

Nationality of asylum seekers

Among the 185 asylum seekers, 166 (89.7%) were African (Figure 1). Most of them came from Nigeria (n = 43; 23.2%), followed by The Gambia (n = 30; 16.2%), Mali (n = 20; 10.8%), Senegal (n = 17; 9.1%), Ivory Coast (n = 14; 7.5%) and Guinea (n = 12; 6.4%). In 17 (9.1%) cases, the victims were Asian, and mostly came from Pakistan (n = 10; 5.4%). In two (1.0%) cases, they were from New Guinea, Oceania.

Figure 1.

Native countries of asylum seekers from Africa.

Countries of alleged events

The majority of the alleged torture events happened in Nigeria (n = 35; 18.9%), The Gambia (n = 27; 14.5%) and Libya (n = 24 cases; 12.9%; Table 1). In most cases, victims said they had been tortured in their native country; in 14.0% of cases, the aggression took place in a different country, especially in Libya.

Table 1.

Countries of alleged events.

Countries	n (%)
Nigeria	35 (18.9%)
The Gambia	27 (14.5%)
Libya	24 (12.9%)
Mali	19 (10.2%)
Senegal	17 (9.1%)
Ivory Coast	13 (7.0%)
Guinea	11 (5.9%)
Pakistan	9 (4.8%)
Burkina Faso, Ghana	4 (2.1%) each
Afghanistan, Chad	3 (1.6%) each
Angola, Bangladesh, Cameroon, Mauritania	2 (1.0%) each
Congo, Eritrea, Guinea Bissau, India, Niger, New Guinea, Togo, Turkey	1 (0.5%) each

Medical examination distribution from September 2008 to September 2017

The cooperation between the municipality of Brescia and the Institute of Forensic Medicine started in September 2008. Between September 2008 and September 2017, 185 asylum seekers underwent a medical examination. During the 10-year period, the Institute has been increasingly involved in the forensic evaluation of asylum seekers, with numbers reaching their highest in the last three years (144 cases; 61.6%).

Sex and age distribution of victims

Almost all the asylum seekers were male (n = 174; 94.0%). At the time of the alleged torture, the victims were predominantly young: most victims (89.1%) were aged between 11 and 30 years; five (2.7%) were aged ≤10 years, while 15 (8.1%) were older, as shown in Table 2. In 22% of cases, the victims made reference to more than one event at different times. In such cases, we took into account the age people were when they were first tortured. At the time of the medical examination, all the asylum seekers were aged ≥18 years (range 18–49 years), and the mean age was 26 years.

Table 2.

Age distribution of asylum seekers.

Age groups (years)	At time of torture, n (%)	At time of examination, n (%)
5–10	5 (2.7%)	– (–)
11–20	79 (42.7%)	34 (18.3%)
21–30	86 (46.4%)	118 (63.7%)
31–40	14 (7.5%)	26 (14.0%)
41–50	1 (0.5%)	7 (3.7%)

Motive of alleged torture

In more than half (n = 106; 57.3%) of the cases, the alleged torture was related to political motives. In 28 (15.1%) cases, the perpetrator was a family member, and in 23 (12.4%) cases, the victims were persecuted because of their religious beliefs. In 17 (9.1%) cases, the aggression happened during a criminal act (as a robbery). In six (3.2%) cases, it was related to ethnic discrimination. In five (2.7%) cases, the victims were tortured at their workplace.

Method of injuries

Blunt instruments (sticks, canes, batons, clubs, rods) were the most frequent means of injury used by the perpetrators (n = 122; 33.8%), followed by sharp instruments (knives, axes, blades, swords, cutters) which were used in 84 (23.3%) cases and beating, punches and kicks used in 42 (11.6%) cases. Other means of injury were adopted in a lower percentage of cases, as shown in Table 3. In several cases, the victims were not able to describe the injurious instruments because they had been blindfolded or had become unconscious during the torturing process. In other cases, cultural barrier prevented us from clearly assessing the type of instrument used. The majority (n = 125; 67.5%) of the victims declared that they had been injured by more than one method of torture during the same event.

Table 3.

Method of torture.

Method of torture	n (%)
Blunt instruments (sticks, batons, canes, clubs, rods)	122 (33.8%)
Sharp instruments (knives, axes, blades, swords, cutters)	84 (23.3%)
Beats, punches and kicks	42 (11.6%)
Thermal instruments (cigarettes, hot instruments, hot fluids)	35 (9.7%)
Ligature and whips (belts, straps, cables, ropes, wires)	29 (8.0%)
Firearms (shotgun, gun, handgun, rifle)	28 (7.7%)
Asphyxiation	7 (1.9%)
Electrical instruments	5 (1.3%)
Sexual abuse	5 (1.3%)
Chemical substances (acid or caustic substances)	3 (0.8%)

Chronic sequelae

At the time of examination, the most representative signs of the alleged torture were dermatological findings (97.8% of all asylum seekers), especially scars, alterations of the nail matrix, lack of toe nails, alopecia or signs of falanga (Figure 2). Other chronic sequelae observed were orthopaedic findings in 32 cases (muscle injuries, deformity of extremities, amputations), dental injuries in 11 cases (dental fractures, teeth loss), ophthalmic findings in seven cases (eyeball avulsion, eyeball atrophy, low vision), genitourinary findings in five cases (clitoridectomy, labia minora lesions, urinary trauma), psychiatric illness in three cases (post-traumatic stress disorder), neurological impairments in two cases and otoiatric disease in one case (deafness due to a blunt-force trauma). In several cases, the asylum seekers referred to non-specific chronic somatic symptoms (headache, neck pain back pain, abdominal pain, muscle pain, pain in knee or hips, sexual dysfunction, gastrointestinal symptoms, anal pain) and psychological complaints (tiredness, weakness, sleeplessness, memory difficulties, nightmares and depression mood, fear of not being able to have children).

Figure 2.

Chronic sequelae of alleged torture.

Anatomical regions involved

The most commonly involved anatomical regions were the lower and the upper limbs (23.6% and 20.5%, respectively), followed by the head (23.2%), thorax (10.1%) and back (6.6%; Figure 3). In 49 (8.8%) cases, the victims had injurious signs in almost all anatomical areas. Radiological evaluation (x-ray, ultrasound, CT and electromyography) was performed in 15 cases, mostly in order to reveal fractures, deformities of bones, fragments of bullet or nerve damage. Specialist examinations were carried out in 13 cases: psychiatric and gynaecological in three cases, orthopaedic and ophthalmology in two cases each, urological, otoiatric and surgical in one case each.

Figure 3.

Anatomical regions involved.

Degree of consistency between the lesion and the alleged torture

According to the Istanbul Protocol, with regard to the degree of consistency between the lesion and the report of the alleged torture, the following assessments were made: 10 lesions (3.1%) were ‘diagnostic of’, 21 (6.6%) were ‘typical of’, 96 (30.3%) were ‘highly consistent’, 188 (50.4%) were ‘consistent with’ and one (0.3%) was ‘non consistent’ with the reports provided by the asylum seekers. In about 30% of cases, the victims referred to being hospitalised, and in some of these cases, we observed scars compatible with surgery. In any case, the assessment of the degree of consistency was influenced by the long time gap between the alleged torture and the medical examination (at least two years) and the progressive remodelling of the injury.

Discussion

Torture appears to be a permanent feature of countries that have experienced military coups or have been ruled by oppressive governments.⁶ Even if most countries have officially outlawed torture, many oppressive regimes still practice torture to terrorise and subdue dissident political, ethnic or religious groups. When people flee from their countries, they seek asylum in the country to which they moved. International protection is not given to asylum seekers until the United Nations conducts an examination and confirms their status.⁷ The application of forensic medicine to interpret the signs of torture will guarantee protection to the asylum seekers and reduce the rate of further torture. A systematic forensic evaluation of alleged victims of torture is the only way to protect them. In fact, the United Nations Convention against torture prohibits repatriation of refugees if there is reason to believe they will be tortured again.⁸ However, medical proof of torture is hard to obtain, mainly because the means used show few signs,⁶ often represented by scars. Medical evaluations documenting the existence of such scars can provide powerful evidence that increases the likelihood of asylum being granted.⁹ It is especially helpful if examiners have experience of working within the legal system and have knowledge of the immigration process.¹⁰ This is the reason why this kind of study should always be conducted by forensic physicians. The first important aspect of forensic evaluation is to collect information according to the alleged torture to which the asylum seeker was subject. Each of our cases required an interpreter because differences in language and culture are the first challenge the forensic pathologist has to face. In some case, the interpreter had difficulty translating the history because of the different Arabic dialects and the low level of instruction of the asylum seekers. Another crucial aspect of the forensic evaluation is the analysis of lesions through observation and description in order to verify the correlation between the type of lesions seen during the clinical examination and the story told by the asylum seeker through the interpreter. The doctor has to link up what the body reveals and what the story tells, even if a long period has lapsed since the alleged violence,¹¹ in accordance with the principles adopted in the Istanbul Protocol. The study revealed that the majority of the torture events took place in Nigeria, Gambia and Libya – countries ruled by oppressive governments. As previously stated, political motives were often the reason why the asylum seekers were tortured.^6,11 It is important to remember that Libya is a country of transit for African asylum seekers because of its geographical location, representing a connection between Africa and Italy. Despite the escalation of conflicts in Libya, migratory flows into the country continue amid widespread human-rights abuse perpetrated against asylum seekers. According to the United Nations High Commissioner for Refugees and the International Organization for Migration, more than 141,000 people travelled from Libya to Italy in 2014.¹² This study confirmed that Libya was the third most likely place for torture. The collected data revealed a strong male dominance among the asylum seekers, with an average age of 21–30 years, in accordance with national and the international trends.^6,7,13–16 The asylum seekers were examined at least two years after the alleged torture, as shown in other studies.^2,17 Therefore, in most cases, scars were the only type of sequelae that could be seen. As known, the more recent an injury is, the easier it is to date it by the appearance of the wound; dating is usually impossible after six months.¹⁸ Blunt instruments were the most frequently used injurious means, as already said in other studies, which noted that beating was frequently applied as a torture method, leading to blunt trauma scars.¹⁹ Nevertheless, the study allowed us to identify sequelae connected to a particular way of torturing people such as falanga (i.e. the act of beating the soles of the victim’s feet repeatedly). As reported by other authors,^20,21 the ritual scar tattoo must be differentiated: scarifying involves scratching, etching, burning or superficially cutting designs or pictures into the skin. In some cases, we observed keloid scars, typical in Africans, which make it more difficult to establish the degree of compatibility with the alleged injury method. Finally, the most commonly involved anatomical regions were both the lower and upper limbs in accordance with previous studies,^9,22 perhaps because limbs are often used as a means of self-protection from injury and harm.

In conclusion, although torture is banned worldwide by international laws, it remains a relevant matter. This study confirmed that medical forensic examinations together with the Istanbul Protocol are essential to recognise the victims of torture and to help them to obtain international protection through refugee status or subsidiary or humanitarian protection.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This research received no specific grant from any funding agency in the public, commercial or not-forprofit sectors.

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